Archives for: February 2003

STUDY: Body fat distribution is a more powerful predictor than is BMI for risk factors, diseases, and mortality

JOURNAL: Am J Clin Nutr. 2002; 76:743-9; 699-700

AUTHORS: Michael J. Lean and Thang S. Han

ABSTRACT: Waist circumference is a better indicator of cardiovascular (CV) risk than is body mass index (BMI), according to results from the National Health and Nutrition Examination Survey (NHANES) III published the American Journal of Clinical Nutrition.

COMMENTARY: Body fat distribution is a more powerful predictor than is BMI for risk factors, diseases, and mortality. Measurements that are more sensitive to individual differences in abdominal fat might be more useful than BMI for identifying obesity-associated risk factors.

Waist circumference correlated more directly than did BMI with overall CV risk. Cutoffs of 90 cm (35 inches) for men and 83 cm (33 inches) for women we found. To minimize CV risk, they recommend advising patients with waist circumference at least as large as the cutoff value to lose weight.

Waist circumference is more closely linked to CV disease risk factors than is BMI [so] it is inappropriate to base waist circumference thresholds on their association with BMI thresholds.

ABSTRACT: A comparison of two different surgical techniques used to fuse vertebrae together and thereby repair unstable sections of the back found that while men experienced fewer temporary complications after undergoing the less-invasive operation, they were much more likely to suffer ejaculation problems caused by nerve damage.

COMMENTARY: During the more invasive "mini-open" procedure, doctors reach the diseased vertebrae by making a series of small incisions, while in the less invasive laparoscopic or "keyhole" approach, doctors use a small video camera and specialized tools inserted through even smaller incisions to repair the area.

Researchers based at the Emory Clinic in Atlanta, Georgia, reviewed the records of 98 patients who had undergone either mini-open or laparoscopic procedures, and found that nearly 18% of mini-open patients experienced complications, as opposed to only 4% of those given the laparoscopic procedure.

However, the investigators also found that 45% of men who underwent laparoscopy experienced a condition known as retrograde ejaculation after the procedure, during which they are able to become aroused and have an erection, but cannot ejaculate any semen. This complication was seen in only 6% of the men who received the mini-open surgery, the authors note. The researchers were unable to determine how long the problem lasted.

According to the report in Neurosurgery, Haid's team found that preparation and procedure time was longer in patients who underwent laparoscopy, while patients often needed to stay in the hospital a bit longer after the mini-open procedure.

Haid explained that given the relatively high risk of ejaculation problems following the laparoscopic approach, he often recommends that younger men opt for the mini-open procedure. Losing the ability to ejaculate will affect a man's fertility, he pointed out, and also likely cause some significant emotional effects.

ABSTRACT: Continuous hormonal replacement therapy (HRT) is associated with an increased risk of lobular breast cancer but not of ductal carcinoma.

COMMENTARY: "The incidence of invasive lobular carcinoma has been increasing among post-menopausal women in some parts of the U.S," writes Janet R. Daling, PhD, from the Fred Hutchinson Cancer Research Center in Seattle, Washington, and colleagues. "Part of this may be due to changes in classification over time. However, the use of combined estrogen and progestin HRT has also increased during the last decade and may account in part for the increase in invasive lobular breast cancer."

This study used data from the NICHD Women's Contraceptive and Reproductive Experiences (CARE) Study, a large case-control breast cancer study of white and African-American women. The investigators conducted in-person interviews of 1,749 postmenopausal women diagnosed with their first invasive breast tumor before the age of 65 years, and compared their responses with those of 1,953 postmenopausal controls identified through random digit dialing.

History of use of unopposed estrogen therapy was not associated with an increase in risk of any histologic type of breast cancer. Women currently using combined HRT had twice the risk of invasive lobular breast cancer.

Although the increase in risk was greater for mixed lobular-ductal than for the pure lobular type, this difference was not statistically significant.

Women who used continuous combined HRT (more than 25 days per month of progestin) for at least five years appeared to be at greater risk of lobular breast cancer than those who used sequential HRT (fewer than 25 days per month of progestin. Use of combined HRT was not associated with risk of ductal breast cancer.

"Post-menopausal women who take combined HRT appear to be at an increased risk of lobular breast cancer," the authors write.

Data from this study suggest that neither unopposed estrogen-HRT use nor combined HRT substantially increase the risk of ductal breast cancer among women less than 65 years of age.

COMMENTARY: The researchers studied 15 patients with hyperhomocysteinemia and coronary artery disease. They were randomized to daily treatment with folic acid 5 mg in combination with cobalamin 400 mcg or to placebo.

At the end of the 6-month study, homocysteine levels fell by 31% in the

combination group, but did not change in placebo patients.

Furthermore, although at baseline, all patients showed severe coronary

ABSTRACT: Some vitamin and dietary supplements are sporting a new certification seal from the U.S. Food and Drug Administration (FDA) designated representative in hopes of assuring consumers that the product lives up to its ingredient labeling claims.

COMMENTARY: The United States Pharmacopeia (USP), an independent agency that serves as the government's official compendium for dietary supplement standards, has begun to issue the certification on hundreds of products that it has independently tested as part of its Dietary Supplement Verification Program (DSVP).

This new program is voluntary and open to all manufacturers of dietary supplements operating in the U.S., a $17-billion-a-year market that includes vitamins, minerals, herbs, botanicals, and sports supplements sold over the counter and consumed by two of every three Americans.

To receive the certification, manufacturers must submit products they select to a "vigorous" seven-step testing and evaluation process that the USP says it ensures meets all labeling claims — first in independent laboratories and then on store shelves. This process includes testing and auditing of declared ingredients, their amounts or dosages, and meeting requirements of limits on contaminants.

So far, hundreds of supplements by two leading manufacturers have been tested and issued the certification. Products that will receive the certification label include those by Nature Made, which just began to hit shelves at some 30,000 stores nationwide, and those under the Kirkland brand, which will be displayed at Costo stores beginning next week.

Together, Nature Made and Kirkland produce about 30% of all vitamins and minerals consumed nationally, and about 20% of the total supplement market, said Richard Wailes, USP's head of sales and marketing. Four other manufacturers have signed up for the certification program and their products will carry the "Dietary Supplement Verified" certification in 2003.

Under the program, manufacturers can submit any products they choose and pay for all testing by USP, which has been establishing drug and other product standards since 1820 and has worked hand-in-hand with the FDA since the federal agency was created in 1938.

Because the FDA regulates dietary supplements as foods and not "conventional" medicines, manufacturers typically do not have to get FDA approval before producing or selling dietary supplements. The FDA can take action only if a product is deemed unsafe and is already on the market.

STUDY: Muscle strength and the degree of abdominal obesity were directly related to BMD

JOURNAL: J Int Med 2002;252:000-000.

AUTHORS: Dr. Kerry J. Stewart

ABSTRACT: Although mild exercise has been shown to reduce the risk of heart disease, it does not appear to be osteoprotective, according to findings from a recent study.

COMMENTARY: Mild physical activity does not seem to be "sufficient to hold off or attenuate the age-related decline in bone with aging," said lead author Dr. Kerry J. Stewart, from Johns Hopkins University in Baltimore.

While mild activity and aerobic fitness did not affect bone mineral density (BMD), muscle strength and the degree of abdominal obesity were directly related to BMD, according to the report published in the Journal of Internal Medicine.

Although being fat may be good for bone density, gaining weight is not the answer because of the harmful effects of obesity on many other aspects of health.

Dr. Stewart's team studied the effects of mild physical activity in 38 men and 46 women, 55 to 75 years of age, with high normal blood pressure or mild hypertension. None of the participants exercised on a regular basis.

Neither overall aerobic fitness nor participation in mild physical activity had a significant effect on BMD, the researchers note. But muscle strength, as well as abdominal obesity, was associated with denser bones.

They found that being more fat and having stronger muscle, which is common in fatter people, along with hormone replacement therapy, had the most influence on bone. In particular, having more abdominal fat was most strongly linked to bone density.

Exactly how abdominal obesity may promote increases in BMD is unclear, but Dr. Stewart suggested that the hormone leptin may be involved. Leptin levels tend to be higher in obese people, he explained, and findings from animal studies indicate that leptin increases the activity of bone cells.

STUDY: TSH level between 3.0 and 5.0 uU/ml ...should be considered suspect.

JOURNAL:

AUTHORS:

ABSTRACT: Major Reversal at American Association of Clinical Endocrinologists Regarding TSH Levels and Diagnosing Hypothyroidism

COMMENTARY: In what constitutes a fairly dramatic reversal of its previous doctrine regarding how hypothyroidism should be diagnosed, the American Association of Clinical Endocrinologists (AACE) has said that:

"Even though a TSH level between 3.0 and 5.0 uU/ml is in the normal range, it should be considered suspect since it may signal a case of evolving thyroid underactivity."

This is the first time a conventional U.S. medical organization has acknowledged that the upper half of the TSH test's normal range may not in fact be normal, but rather, evidence of developing hypothyroidism, or a level that is potentially able to cause hypothyroidism symptoms in patients.

The conventional endocrinology doctrine has, for several decades, dictated that a TSH level that is in the so-called "normal range" indicate a "euthyroid" -- or normal -- state for the thyroid, and thus does not warrant treatment, despite clinical symptoms.

In fact, most patients who have numerous clinical symptoms of hypothyroidism, as well as a family history of thyroid disease -- and even those who have tested positive for the presence of thyroid antibodies indicative of autoimmune Hashimoto's Disease -- are declined treatment by endocrinologists and other physicians unless TSH levels are elevated above the laboratory's "normal range" -- which is typically a TSH level anywhere from 4.7 to 6.0 uU/ml.

Many people who are suffering thyroid symptoms. . . may now be considered hypothyroid and eligible to be diagnosed and treated.

The AACE's acknolwedgement lags years behind the efforts of a number of pioneering physicians and patient advocates -- as well as what patients themselves have suspected.

Almost four years ago, for example, Dr. A P Weetman, a professor of medicine, wrote in the article "Fortnightly review: Hypothyroidism: screening and subclinical disease" which appeared in the 19 April 1997 issue of the British Medical Journal, the following groundbreaking statement:

". . . even within the reference range of around 0.5-4.5 mU/l, a high thyroid stimulating hormone concentration (>2 mU/l) was associated with an increased risk of future hypothyroidism. The simplest explanation is that thyroid disease is so common that many people predisposed to thyroid failure are included in a laboratory's reference population, which raises the question whether thyroxine replacement is adequate in patients with thyroid stimulating hormone levels above 2 mU/l."

"Why are we following a test which has no correlation with clinical presentation? The thyroidologists by consensus have decided that this test is the most useful for following treatment when in fact it is unrelated to how the patient feels. The consequences of this have been horrendous. Six years after their consensus decision Chronic fatigue and Fibromyalgia appeared. These are both hypothyroid conditions. But because their TSH was normal they have not been treated. The TSH needs to be scrapped and medical students taught again how to clinically recognize low thyroid conditions."

Other physicians have been working with antibodies testing to evaluate thyroid function, and in some cases treating patients with normal range TSH values who had thyroid antibodies evident of the autoimmune disease process.

Elizabeth Vliet, MD, who runs the popular women's health centers, Her Place and who is author of the bestselling book, Screaming to be Heard: Hormonal Connections Women Suspect...and Doctors Ignore, has never believed that TSH tests are the indicator of a woman's thyroid health. Since the mid 1990s, Dr. Vliet has been saying that symptoms, along with elevated thyroid antibodies and normal TSH, may be a reason for treatment with thyroid hormone. Here's a quote from her book:

"The problem I have found is that too often women are told their thyroid is normal without having the complete thyroid tests done. Of course, what most people, and many physicians, don't realize is that...a 'normal range' on a laboratory report is just that: a range. A given person may require higher or lower levels to feel well and to function optimally. I think we must look at the lab results along with the clinical picture described by the patient...I have a series of more than a hundred patients, all but two are women, who had a normal TSH and turned out to have significantly elevated thyroid antibodies that meant they needed thyroid medication in order to feel normal. This type of oversight is particularly common with a type of thyroid disease called thyroiditis, which is about 25 times more common in females than males...a woman may experience the symptoms of disease months to years before TSH goes up..."

The current TSH levels used by laboratories to define the "normal" range of thyroid function, and the use of the TSH test as primary means of diagnosis need to be significantly reevaluated. The .5 to 5.5 "normal range" for thyroid function is just not enough information for diagnosis anymore.

Research reported in the British Medical Journal found that TSH levels above 2 are likely not normal, and instead include people at high risk to develop thyroid disease. This means that the real "normal range" is probably far narrower, and more concentrated in the lower end of the range.

New studies need to be conducted to look at this issue comprehensively, evaluating the true normal range for a population of individuals who have no thyroid antibodies, and who do not ever go on to develop thyroid disease in their lifetimes.

In February of 2000, a groundbreaking study estimated that as many as 13 million Americans had undiagnosed thyroid disease. The vast majority of these people would be women, suffering from undiagnosed hypothyroidism. This Colorado Thyroid Disease Prevalence Study used the standard diagnostic criteria to define hypothyroidism -- that the TSH had to exceed the lab's normal range, which for the purposes of this study, was 5.1 uU/ml. Broadening the lab diagnostic criteria then, to levels above 3 would mean that the Colorado Thyroid Disease Prevalence Study suggests that many more than 13 million Americans are likely to be defined as hypothyroid.

ABSTRACT: Frequent mountain-biking may reduce fertility in men, according to a small Austrian study that adds fodder to a debate over cycling and male sexual function.

COMMENTARY: The research suggests frequent jolts and vibration caused by biking over rough terrain may cause abnormalities, including small scars within the scrotum and impaired sperm production.

The abnormalities were found in professional mountain bikers and other “extreme” bikers who logged at least 3,000 miles yearly — or an average of more than two hours a day, six days a week.

Dr. Ferdinand Frauscher, a urology-radiology specialist at University Hospital in Innsbruck, Austria, said he studied about 55 avid mountain bikers and found nearly 90 percent had low sperm counts and scrotal abnormalities.

Only 26 percent of the 35 non-bikers he studied had similar damage, according to research presented at this week’s annual meeting of the Radiological Society of North America.

Whether the abnormalities were severe enough to make fathering a child difficult is uncertain, though some of the bikers studied had already experienced difficulty conceiving.

Participants were aged 17 to 44. His study looked at fertility rather than impotence, which was linked to recreational cycling in research heavily publicized in 1997. The earlier findings, by Boston University impotence specialist Dr. Irwin Goldstein, were construed by many cycling aficionados to suggest that men should avoid any cycling sports.

Some doctors thought Goldstein’s findings were overstated, but the issue has prompted a mini-industry of bicycle seats designed to avoid the compression of penile arteries that Goldstein said occurs during cycling.

Such problems may occur on narrow, racing-type seats, Frauscher said. Some newer, wider designs feature holes or gaps to avoid pressure, but these likely would have no effect on the scrotal damage found in the Austrian study, which may be caused by jolting over rough terrain rather than artery compression, Frauscher said.

Frauscher said men shouldn’t avoid mountain biking because of the study, but should perhaps consider investing in bikes with shock absorbers or suspension systems designed to reduce the jolting.

Stanford University urologist Dr. Robert Kessler said he was skeptical of Frauscher’s findings. Scrotal varicose veins, which were among the abnormalities Frauscher linked to mountain biking, are usually congenital and not linked to trauma, Kessler said.

Dr. Eduardo Randrup, a urologist at Ochsner Clinic in New Orleans, said the link is plausible but not necessarily cause for alarm. The damage Frauscher found “may well be reversible” and likely would not occur from recreational cycling, Randrup said.

Dr. Sangili Chandran, a sports medicine specialist at Christ Hospital and Medical Center in the Chicago suburb of Oak Lawn, said other studies have found similar results but, like Frauscher’s, have been too small to be conclusive.

Even if the results are corroborated in future studies, very few mountain biking enthusiasts are logging enough miles to worry about any fertility impairment.

ABSTRACT: The production of cytokines after melatonin stimulation by mononuclear cells from patients with asthma suggests that melatonin may exacerbate their symptoms, according to a report in the American Journal of Respiratory and Critical Care Medicine.

COMMENTARY: Patients with nocturnal asthma show circadian variations in airflow limitation, the authors explain, and melatonin is a key regulator of circadian rhythms as well as an important immunomodulatory in allergic diseases.

Dr. E. Rand Sutherland and colleagues from National Jewish Medical and Research Center and the University of Colorado Health Sciences Center in Denver, Colorado evaluated the effect of melatonin stimulation on peripheral blood mononuclear cell (PBMC) cytokine production at 4 a.m. and 4 p.m. in 5 normal control subjects, 6 patients with nocturnal asthma, and 12 patients with non-nocturnal asthma.

Melatonin stimulation significantly increased the production of IL-1, IL-6, and TNF-alpha by zymosan-stimulated PBMCs in all subject groups at both stimulation times, the authors report.

Nocturnal asthma patients had higher IL-1 production levels than normal subjects did, the report indicates, though (for both groups) 4 a.m. and 4 p.m. levels did not differ. Patients with non-nocturnal asthma had IL-1 production levels similar to controls subjects at 4 a.m., but these levels increased nearly 5-fold at 4 p.m.

Melatonin-stimulated IL-6 production patterns were very similar to those seen with IL-1 production, the results indicate.

In contrast, both nocturnal asthma patients and non-nocturnal asthma patients showed substantially higher melatonin-stimulated TNF-alpha production at 4 p.m. than at 4 a.m., the researchers note, whereas control subjects showed similar increases at both times.

These results suggest differential immunomodulatory effects of melatonin based on asthma clinical phenotype and may indicate an adverse effect of exogenous melatonin in asthma. For these patients, avoidance of melatonin may be appropriate until further information about the clinical effect of melatonin in asthma becomes available.

ABSTRACT: Most women over 30 can skip the annual Pap test for cervical cancer, and instead safely have the check only every two to three years, the American Cancer Society said.

COMMENTARY: Cervical cancer grows so slowly that women have plenty of time to be tested and have any preventive treatment, the organization advised.

The new guidelines will have a major impact on the number of women who are over-screened and over-treated.

Because most cervical precancers grow slowly, having a test every two to three years will find almost all cervical precancers and cancers while they can be removed or treated successfully.

Cervical cancer affects nearly 500,000 worldwide every year. Detected early, it can be easily treated but it will kill an estimated 300,000 women this year, mostly in the developing world where screening is not routine.

In the United States, the American Cancer Society estimates that 13,000 women will develop cervical cancer this year, and about 4,100 women will die.

Cervical cancer is usually caused by the sexually transmitted human papilloma virus. Pre-cancerous changes can be detected with the Pap smear test, and suspect areas removed before cancer develops.

The new guidelines say testing every two to three years is usually sufficient for women older than 30 who have had several “clear” tests.

"A doctor may suggest getting the test more often if a woman has certain risk factors such as human immunodeficiency virus (HIV) infection or a weakened immune system. Women 70 years of age and older who have had three or more normal Pap test results and no abnormal results in the last 10 years may choose to stop cervical cancer screening,” the society said in a statement.

As long as you have had clean paps and no risks then you can spread out your screening exams.

ABSTRACT: A landmark study offers the strongest evidence yet that simmering, painless inflammation deep within the body is the single most powerful trigger of heart attacks, worse even than high cholesterol.

COMMENTARY: The latest research is likely to encourage many doctors to make blood tests for inflammation part of standard physical exams for middle-aged people, especially those with other conditions that increase their risk of heart trouble.

The study, based on nearly 28,000 women, is by far the largest to look at inflammation’s role, and it shows that those with high levels are twice as likely as those with high cholesterol to die from heart attacks and strokes.

Over the past five years, research by Dr. Paul Ridker of Boston’s Brigham and Women’s Hospital has built the case for the “inflammation hypothesis.” With his latest study, many believe the evidence is overwhelming that inflammation is a central factor in cardiovascular disease, by far the world’s biggest killer.

Inflammation can be measured with a test that checks for C-reactive protein, or CRP, a chemical necessary for fighting injury and infection. The test typically costs between $25 and $50.

Diet and exercise can lower CRP dramatically. Cholesterol-lowering drugs called statins also reduce CRP, as do aspirin and some other medicines.

Doctors believe inflammation has many possible sources. Often, the fatty buildups that line the blood vessels become inflamed as white blood cells invade in a misguided defense attempt. Fat cells are also known to turn out these inflammatory proteins. Other possible triggers include high blood pressure, smoking and lingering low-level infections, such as chronic gum disease.

Inflammation is thought to weaken the fatty buildups, or plaques, making them more likely to burst. A piece of plaque can then lead to a clot that can choke off the blood flow and cause a heart attack.

For the first time, Ridker’s study establishes what level of CRP should be considered worrisome, so doctors can make sense of patients’ readings. However, experts are still divided over which patients to test and how to treat them if their CRP readings are high.

Some, such as Dr. Richard Milani of the Ochsner Clinic in New Orleans, recommend a CRP check for virtually anyone getting a cholesterol test. “If I have enough concern to check a patient’s cholesterol, it seems naive not to include an inexpensive test that would give me even more information,” he said.

Ridker said he believes a high CRP reading can help doctors persuade people with low cholesterol that they still need to diet and exercise.

“The CRP test can predict risk 15 to 25 years in the future,” Ridker said. “We have a long time to get our patients to change their lifestyles, and the change does not have to be huge — modest exercise, modest weight loss and stop smoking.”

Ridker’s latest study is based on an eight-year follow-up of 27,939 volunteers in the Women’s Health Study. About half of heart attacks and strokes occurred in those with seemingly safe levels of LDL, the bad cholesterol.

The lowest risk was in women whose CRP readings were below one-half milligram per liter of blood. It more than doubled when readings went over about three.

You've heard it before: Eat sensibly and get some exercise. But new findings on the dangers of inflammation offer still another reason to shape up.

Doctors say that both inactivity and obesity increase inflammatory proteins that can trigger heart attacks. People can substantially lower their levels of these proteins simply by improving their living habits. Even modest changes help, though studies show that vigorous exercise and a strict diet can cut inflammation levels in half in just three months.

Some research suggests that moderate alcohol consumption and fish oil are good for inflammation levels.

So too are giving up smoking and keeping blood pressure under control.

A variety of drugs and supplements may also do the trick. Ask your doctor to test you.

STUDY: People taking vitamin E supplements for at least 10 years were less likely to die from bladder cancer.

JOURNAL: Am J Epidemiol 2002;156:1002-1010

AUTHORS: Dr. Jacob

ABSTRACT: People who take vitamin E regularly are less likely than those in the general population to die of bladder cancer, researchers report, but it is not clear if the vitamin itself or some lifestyle factor is responsible for the reduced risk.

COMMENTARY: Researchers tracked nearly 1 million US adults for 16 years and interviewed them about their diet. Those who reported taking vitamin E supplements for at least 10 years were less likely to die from bladder cancer, compared with adults who reported shorter durations of use.

In contrast, there was no association between regular vitamin C use and bladder cancer mortality, report researchers in the December issue of the American Journal of Epidemiology.

The current findings support those of two previous studies that showed an inverse relationship between bladder cancer risk and vitamin E intake.

Exactly how vitamin E may protect against bladder cancer is unclear. It might result from its antioxidant effect in neutralizing DNA-damaging free radicals. Alternatively, vitamin E may boost the immune system or prevent the formation of carcinogenic nitrosamines.

However, if vitamin E's antioxidant properties are responsible for the protective effect, it is not clear why vitamin C use confers no protection against the malignancy.

Dr. Jacob emphasized that further studies are needed to verify the current results and to possibly shed light on vitamin E's mechanism of action.

ABSTRACT: The blockbuster arthritis drug Celebrex doesn’t protect the stomach from dangerous bleeding ulcers as well as thought, a study suggests.

COMMENTARY: CELEBREX AND two similar new anti-inflammatory drugs are heavily advertised as being safer for arthritis patients based on earlier research that found they caused fewer ulcers and other gastrointestinal complications than older anti-inflammatory medicines.

Together, the three new drugs have annual sales exceeding $6 billion.

But their safety has been called into question recently. The new study, which focused on arthritis patients at high risk of recurrent ulcers, escalates the controversy involving Celebrex, showing nearly 10 percent each year would develop another bleeding ulcer.

The study found the same thing for an older anti-inflammatory drug combined with ulcer medicine Prilosec, which doctors often give arthritis patients to protect their stomachs. In addition, neither treatment protected as many patients from dangerous kidney complications as past studies showed, the researchers said.

The Hong Kong researchers and some other experts said the results, while showing the treatments work the same, indicate more study is needed on preventing bleeding stomach ulcers in vulnerable older people who for years ease joint pain with nonsteroidal anti-inflammatory drugs, or NSAIDs.

“I think patients and doctors need to be aware ... there is a risk of gastrointestinal bleeding and there is a risk of renal toxicity,” so high-risk patients should be monitored closely by their doctor, said Dr. John H. Klippel, medical director of the Arthritis Foundation.

These drugs, which also include Vioxx and Bextra, do not block action of the cox-1 enzyme, which protects the lining of the stomach. Older NSAIDs such as diclofenac block both cox enzymes, and so can cause stomach irritation and exacerbate ulcers.

Of the study patients receiving Celebrex, about 5 percent had recurrent bleeding during the six months of research, compared with about 6.5 percent for those getting diclofenac and Prilosec.

However, that equates to annual rates of about 9 percent and 11 percent, respectively, Dr. David Y. Graham of the Veterans Affairs Medical Center in Houston wrote in an accompanying editorial. “The results were unexpected: Neither regimen provided a good or even acceptable level of protection from recurrent bleeding,” Graham wrote.

Both treatments did a good job in reducing pain and enabling patients to perform daily activities over the six-month experiment.

But about 25 percent of those in the Celebrex group and 31 percent in the diclofenac/Prilosec group suffered kidney complications, including high blood pressure and swollen ankles; about 6 percent in each group suffered life-threatening kidney failure.

Klippel said that shows doctors must monitor high-risk patients on these anti-inflammatory drugs for increased pain and bloody stools indicating an ulcer flareup. They also should watch for swelling in the extremities and elevated blood pressure — signs the kidneys can’t excrete enough fluid.

“Physicians should avoid prescribing these drugs to patients with known kidney diseases, poorly controlled hypertension and heart failure."

We have many alternatives to these drugs. Let's make sure that we educate patients as to the best choices for them.

ABSTRACT: People who are overweight at 40 are likely to die at least three years sooner than those who are slim, meaning that in terms of life expectancy, being fat during middle age is just as bad as smoking.

COMMENTARY: Nonsmokers who were classified as overweight, but not obese, lost an average of three years off their lives. Obese people died even sooner. Obese female nonsmokers lost an average 7.1 years, while men lost 5.8 years.

Scientists have long known that overweight people have shorter life expectancies, but few large-scale studies have been able to pinpoint how many years they lose.

“This study is saying that if you are overweight by your mid-30s to mid-40s, even if you lose some weight later on, you still carry a higher risk of dying,” said Dr. Serge Jabbour, director of the weight-loss clinic at Thomas Jefferson University Hospital in Philadelphia. “The message is that you have to work early on your weight. If you wait a long time, the damage may have been done.”

For smokers, the results were even worse. Obese female smokers died 7.2 years sooner than normal-weight smokers, and 13.3 years sooner than normal-weight nonsmoking women. Obese male smokers lived 6.7 years less than trim smokers, and 13.7 years less than normal-weight nonsmokers.

The results were culled from vital statistics collected from 3,457 volunteers in Framingham, Mass., from 1948 to 1990. The data were analyzed by researchers at Erasmus Medical Center and the University of Gronigen in the Netherlands.

Obesity is defined as having a body-mass index of 30 or above. The index is a measure of weight relative to height. Healthy weight is a BMI of less than 25.